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Tara H. Lines et al
Fig. 1. Provider responses on attribution in Infectious Diseases Consult patient case scenario. Note: The question read as follows: “The ICU consults Infectious Diseases who recommends narrowing to ceftriaxone and metronidazole. To whom should the antimicrobial be attributed at this time?” Specialty abbreviations: CC, critical care; EM, emergency medicine; ID, infectious diseases; MED, medicine; SG, surgery.
Table 1. Provider Levels of Concerna Regarding AU Feedback, Stratified by Clinical Specialty Question Domain
Appropriateness of antimicrobial use Accuracy of reporting
Following another provider’s recommendation
Complexity of patient populationd
All Providers 3.4 (1.2) 3.8 (1.2)
3.3 (1.3) 3.6 (1.3)
Critical Care 3.7 (1.7) 4.0 (0.8)
3.1 (1.6) 3.7 (1.8)
3.3 (1.2) 4.1 (1.3)
3.7 (1.4) 4.4 (0.8)
a1=no concern, 5=very concerned. bP value is between groups. cP<.005 when comparing infectious diseases to emergency medicine, medicine, and surgery specialty groups. dIncluding immunocompromised, critical illness, multidrug-resistant pathogen history, etc. eP<.005 when comparing surgery to all other specialty groups.
were not the providers that changed therapy the preceding day. Providers across all services agreed on AU attribution for the admission scenario, the transfer to ICU scenario, and the new ICU Team scenario (P>.05 for all across-group comparisons) (Appendix B). Attribution in the ID consult scenario varied sig- nificantly across groups (P=.012), driven by the difference between ID and SG (P=.002 by Bonferroni correction) (Fig. 1).
Feedback preference
Providers wanted AU feedback on a quarterly basis (69%) via e-mail (73%), and they wanted AU reporting to be grouped by service (63%) rather than patient care unit (27%). Among the providers that wanted unit-based reporting, there were proportion- ally more CC providers (60%) compared to EM (17%), MED (18%), and SG (22%) providers for all comparisons (P<.005). Among the 48% of providers who preferred reporting at the individual provider level, there were significantly more ID providers (71%) than SG providers (33%) (P=.004). Most providers wanted to be compared to other providers
within their service (64%). In addition, 60% of providers identi- fied mean AU as the optimal comparison metric when comparing their own AU to that of other providers.
Barriers to feedback
All services were equally concerned that attribution would not account for 2 separate issues: appropriateness of AU and reporting accuracy (Table 1). Moreover, ID providers were significantly less concerned about attribution than EM, MED, or SG providers when a consulting team had provided antimicrobial recommendations (P<.005). Also, CC, ED, MED, and ID providers were more
concerned than SG providers that AU would not account for the complexity of specific patient populations (P<.005 for all comparisons). Moreover, 51% of providers anticipated changing practice based on AU feedback data.
Discussion
In this study, which is the first study to evaluate provider preferences regarding internal AU reporting by quantitative feedback, we found that providers generally agreed on preferred feedback methods, frequency, and metrics. Although assigning responsibility for pre- scribing antimicrobial agents may be difficult, providers agreed on initial attribution, but disagreements arose as care became more complex, with some teams deferring and others accepting respon- sibility. Only a small percentage of respondents attributed anti- microbials to consult services that were not seen as related to the infection, which may pose issues in creating a culture of shared responsibility for antimicrobial stewardship. Although these barriers to acceptance parallel the early struggles assigning responsibility in the mandatory public reporting of healthcare-associated infections, institutions have since been able to successfully implement infection prevention strategies.3,4 In this study, providers preferred to receive service- or provider-
based feedback. As the current AU reporting module utilizes unit- based reporting in addition to facility-wide data in the standardized antibiotic administration ratio, local antimicrobial stewardship programs will play a crucial role in examining provider- or service- level data to identify stewardship opportunities and to increase the acceptability of internal reporting. Awareness of the concerns raised here regarding patient complexity or severity of illness must be considered in implementing feedback reporting systems. While
Emergency Medicine
Infectious Diseases
3.6 (1.2) 3.5 (1.0)
2.3 (1.0)c 3.9 (0.8)
Medicine 3.3 (1.3) 3.8 (1.8)
3.5 (1.7) 3.6 (1.8)
Surgery 3.0 (1.3) 3.6 (1.4)
3.6 (1.8) 2.8 (1.8)e
P Valueb .10 .29
<.001 <.001
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